Trauma in peace and war

Not just for soldiers

Post-traumatic stress disorder (PTSD) has attracted much popular and medical attention in recent decades. It is most often associated with soldiers returned from combat. PTSD is however also found in survivors of sexual abuse, torture and genocide. It can often lead to depression, aggression or suicide.

Trauma, defined as a emotionally scarring experience, is at the heart of PTSD. Until the early 1900s, trauma was the domain of surgeons, not psychotherapists. It meant a violent physical blow to the body, such as a gunshot or a fall from a horse. The subsequent shift in emphasis from the body to the mind involved combat veterans, people caught in the crossfire, women diagnosed with hysteria, and people hurt in railway or industrial accidents.

Spinal trauma or nerve disease?

Victims of railway accidents in Victorian Britain often reported flashbacks and debilitating anxiety or nerves. They were diagnosed with ‘railway spine’, physical trauma to the nerves in the spine. French neurologist Jean-Martin Charcot rejected the idea. He argued the physical jolt disrupted the nervous system, exposing an inherited neurological disease that the body had previously masked. This underlying disease, Charcot argued, was hysteria. Charcot’s theory explained why some victims of railway accidents survived with their nerves intact while others displayed symptoms typical of hysteria including fatigue, trembling, shortness of breath, anxiety and paralysis. It also explained why symptoms of railway spine, like symptoms of hysteria, often disappeared under hypnosis.

Though Charcot’s theory was disputed and soon abandoned, the medical debate had economic and social consequences. Nervous trauma from industrial accidents figured alongside neurasthenia and hysteria in German political debates about degeneration. Germany pioneered workers’ compensation in the 1880s, but critics of this welfare system alleged that increased nerve-related compensation claims proved the working classes were degenerating. German insurance boards consequently rejected the pension claims of trauma survivors. Some survivors argued they had been traumatised twice: by the accident and then by years spent appealing.

Shell shock and related diagnoses

The term ’shell shock’ was coined by a British physician during the First World War and has come to be almost synonymous with PTSD. The diagnosis, however, originally applied only to those cases where soldiers survived an explosion apparently unharmed, yet soon after showed symptoms of spinal or nerve damage. This idea was modelled on railway spine.

Soldiers with symptoms not linked to physical nerve trauma received other diagnoses. These often depended on the severity of their symptoms and sometimes on the soldier’s socioeconomic class. The ‘walking wounded’ and officers tended to be diagnosed with neurasthenia or nervous breakdown. More severe cases were often labelled hysteria. Many German military physicians interpreted soldiers’ debilitating nervous symptoms as a consequence of degeneration rather than trauma. The soldier was blamed, not the situation.

Psychiatrists and neurologists in the First World War used a range of therapies to return traumatized men to the front. These included medical methods such as hypnosis, reflecting Charcot’s influence, and electrotherapy. Non-medical methods included persuasion, electric shock and psychological coercion. However, many men were too scarred to respond, and often languished in asylums.

The road to PTSD

British physician William Rivers pioneered an experimental psychotherapy during the First World War. It was inspired by Sigmund Freud’s work in Vienna with women diagnosed with hysteria. Freud observed certain symptoms of nervous illness were caused by memories too difficult to bear. Rivers encouraged emotionally wounded soldiers to share their memories, nightmares and fears - they should ‘talk through’ emotional traumas to move beyond them.

Emotional understanding of trauma pioneered by Freud dominated military and civilian medicine during the Second World War. Military psychiatrists developed the slogan ‘every man has his breaking point’. This attitude reduced the stigma surrounding battlefield breakdowns and helped traumatised soldiers adapt to peacetime life. The focus was on traumatic combat rather than weakness or disease within the soldier’s nervous system.

Post-war developments in the psychotherapy of trauma resulted from work with people traumatized in Nazi death camps and child abuse survivors. London paediatrician Margaret Lowenfeld developed several influential non-verbal therapies. She used coloured tiles and small toys to help children express emotions they did not have the words to describe. Other developments came through work with soldiers in later wars and civilians uprooted by such conflicts. The 1980 revision of the American Diagnostic and Statistical Manual(DSM), published soon after the Vietnam War, codified the diagnosis today called PTSD. Both soldiers and civilians played important roles in its history.